Embolization of brain arteriovenous malformations with intent to cure: a systematic review

Abstract

OBJECTIVEEndovascular embolization has been established as an adjuvant treatment strategy for brain arteriovenous malformations (AVMs). A growing body of literature has discussed curative embolization for select lesions. The transition of endovascular embolization from an adjunctive to a definitive treatment modality remains controversial. Here, the authors reviewed the literature to assess the lesional characteristics, technical factors, and angiographic and clinical outcomes of endovascular embolization of AVMs with intent to cure.METHODSElectronic databases—Ovid MEDLINE, Ovid Embase, and PubMed—were searched for studies in which there was evidence of AVMs treated using endovascular embolization with intent to cure. The primary outcomes of interest were angiographic obliteration immediately postembolization and at follow-up. The secondary outcomes of interest were complication rates. Descriptive statistics were used to calculate rates and means.RESULTSFifteen studies with 597 patients and 598 AVMs treated with intent-to-cure embolization were included in this analysis. Thirty-four percent of AVMs were Spetzler-Martin grade III. Complete obliteration immediately postembolization was reported in 58.3% of AVMs that had complete treatment and in 45.8% of AVMs in the entire patient cohort. The overall clinical complication rate was 24.1%. The most common complication was hemorrhage, occurring in 9.7% of patients. Procedure-related mortality was 1.5%.CONCLUSIONSWhile endovascular embolization with intent to cure can be an option for select AVMs, the reported complication rates appear to be increased compared with those in studies in which adjunctive embolization was the goal. Given the high complication rate related to a primary embolization approach, the risks and benefits of such a treatment strategy should be discussed among a multidisciplinary team. Curative embolization of AVMs should be considered an unanticipated benefit of such therapy rather than a goal.

Curative treatment for low-grade arteriovenous malformations

“…The role of presurgical embolization has evolved as endovascular techniques continue to be refined, and newer embolic agents (eg, Onyx) are introduced. Many case series have been published demonstrating the low morbidity associated with endovascular embolization, with some rivaling the morbidity of surgical resection alone, but also showing complete angiographic cure with embolization alone 20–23…”

“…Recently, endovascular embolization with the intention of cure has been described in the medical literature. Historically, the rates of complete endovascular obliteration of an AVM are <40% 23 26. In highly select patients with specific anatomical AVM features, complete obliteration approaches 90%.…”

“…Wu et al , in their systematic review of the literature, discuss the angiographic characteristics of an AVM that can be associated with complete endovascular obliteration. These were AVM nidus size <30 mm, located in non-eloquent cortex, deep location, superficial or large arterial feeders with a single arterial pedicle, anatomy allowing for 2–3 cm of embolic material reflux, and unobstructed views of proximal draining veins 23…”

The Comaneci Device for Entering an Acute-Angled Small Feeder during Cerebral Arteriovenous Malformation Embolization: A Novel Technique to Support Microcatheterization

“…Endovascular embolization of AVMs can be a challenging procedure, especially in patients presenting with hemorrhage, in which complete embolization should be achieved. 7 One of the limitations of treatment, especially of small AVMs, is difficult accessibility of feeding arteries due to the complex anatomy of cerebral vessels. Good accessibility can be obtained using the Comaneci, which provides a compliant remodeling mesh, comparable to a compliant balloon, without the drawback of flow disturbance within the parent artery during expansion of the device.…”

Risk factors for hemorrhage of brain arteriovenous malformation

“…Such a practice has been advocated by others too . As it relates to attempted curative embolization, using transarterial or transvenous methods, there are a collection of small series noting high angiographic cure rates for bAVMs using embolization alone, though many of these series note higher rates of clinical complication relative to microsurgery and with limited clinical outcomes or long‐term follow‐up data . Finally, as it relates to the use of adjunctive embolization in radiosurgical practice, there is evidence of reduced obliteration rates relative to nonembolized lesions undergoing radiosurgery …”